Federal Health Care Law Update

1. Federal Health Care Law Update Marc D. Price, D.O. Family Medicine of Malta Mechanicville, N.Y. NYSAFP Board of Directors NYSAFP Advocacy Commission, Chairman AAFP Commission on Government Advocacy, Member

2. Overview • Brief explanation of The Affordable Care Act • Impact of The Affordable Care Act • Consumers • Insurance industry • Physicians • Physician Payment Rule 2011 • Overview of benefits for primary care • HITECH Act • AAFP efforts

3. The Affordable Care Act • 3/23/10 - The Patient Protection and Affordable Care Act • Amended 3/30/10 – Health Care And Education Reconciliation Act • Goal • To end some of the worst abuses by the insurance industry and to award Americans new rights and benefits • 4 Year roll implementation

4. The Affordable Care Act:Impact to the Consumer • Prevent Discrimination against pre-existing conditions, gender and health status • Prohibits denial of children (up to 19 yo)-now • Total prohibition (regardless of age) in 2014 • “Pre-existing condition insurance plan” to bridge the gap • Young adults up to age 26 yo may remain on a parent’s plan-now

5. The Affordable Care Act:Impact to the Consumer • Prohibits insurance companies from rescinding coverage when patients fall ill-now • Continuation of Child Health Insurance Program (CHIP) x 2 more years-now • Removes lifetime dollar limits on “essential benefits”-now • Restricts annual dollar limits • Completely phased out by 2014

6. The Affordable Care Act:Impact to the Consumer • Small business (<25 FTE) tax credits to offset cost of offering employee health insurance • 35% presently (25% for non-profits)-now • 50% by 2014 (35% for non-profits) • Tax credits or cost sharing • Middle class without other affordable alternatives • Early Retiree Reinsurance Program • Assistance to employers to offer insurance to employees retiring between the ages of 55-65 yo-now

7. The Affordable Care Act:Impact to the Consumer • Establishment of Health Insurance Exchanges • For those not offered employer sponsored insurance • Competitive insurance company “marketplace” • Tax credits/matching funds may be used • Same as offered to members of congress

8. The Affordable Care Act:Impact to the Consumer • Ensures Insurance companies to cover those participating in clinical trials • Requires all uninsured individuals to obtain health insurance • Partial or full funding available based on need • Exemptions available if no affordable alternative available • Contested as unconstitutional

9. The Affordable Care Act:Impact to the Consumer • Federal grants to states for Consumer Assistance Programs • Aimed at assisting consumers in understanding and navigating through insurance plans-now • Rights to consumers to appeal coverage decisions • Makes available an external appeal process if consumer is not satisfied with the internal appeal decision-now

10. The Affordable Care Act:Impact to the Consumer • Federal funds offered to states to offer a Community First Choice option • Offer of home based services to disabled individuals prior to institutionalized care-October 2011 • Community Care Transition Program • Helps to transition patients back to community services after hospitalization to prevent readmission-now

11. The Affordable Care Act:Impact to the Consumer • Closing the Medicare “donut hole” in part D drug coverage • 50% discount on name-brand and 7% on generic for 2011-now • Coverage gap gradually phased out by 2020 • Medicare coverage of annual wellness visits • No out-of-pocket cost to the consumer-now • Coverage of preventive services • No out-of-pocket cost to consumer (ie. copay, coinsurance or deductible)-now

12. The Affordable Care Act:Impact to the Consumer • Federal Medical Assistance Percentage (FMAP) • Federal funds to expand Medicaid services • Preventive care-now • Increased ability to cover more individuals and families-now • Availability of Medicaid to those at 133% of the poverty level by 2014 • 100% Federally funded x 3 yrs starting in 2014 then decreasing to 90% federal funding

13. The Affordable Care Act:Impact to the Insurance Industry • Increased expenditure on improvement in health care quality and services • 85% of premium dollars collected by large employer plans (80% individuals and small employer plans)-now • Penalties if measures not met • Decreasing the cost of Medicare Advantage plans to neutrality with general Medicare

14. The Affordable Care Act:Impact to the Insurance Industry • Standardization of billing codes/practices-planning phase • Adoption and implementation of rules and regulations for electronic health exchanges and electronic health records (EHR)-starting • Federal health plans required to collect and report data on racial, ethnic and language disparities-starting

15. The Affordable Care Act:Impact to the Insurance Industry • Federal grants (up to $250 million) to states that already have, or will be implementing measures that require insurance companies to justify premium increases-now • Companies with excessive profits or unjustified increases may not be able to participate in the 2014 health exchanges

16. The Affordable Care Act:Impact to the Insurance Industry • Mandate to the Centers for Medicare and Medicaid Services to develop, support and test innovations in health care delivery and efficiency • Development of the Independent Payment Advisory Board (IPAB) • Directed to develop means by which to extend the Medicare Trust Fund by cutting waste, improving efficiency and increasing quality of delivered care-developing

17. The Affordable Care Act:Impact to the Insurance Industry • Community Living Assistance Services and Supports (CLASS) Act • Creation of a voluntary long-term care insurance program offered through employers • A note about the new rules and insurance plans • These apply to all Medicare and Medicaid programs and any group or employer plans and insurance companies or plans which were started after 3/23/10 • Individual or family plans purchased independently prior to 3/23/10 are not required to adhere to many of these rules and are considered “grandfather” plans

18. The Affordable Care Act:Impact to the Physicians • Expansion of the primary care workforce • Tax incentives, scholarships and loan repayment to work in underserved populations-now • $250 million dedicated to training more primary care providers (physicians, NPs, PAs)-now • Goal of 16,000 more primary care physicians over the next 5 years • Includes funding for support of IT infrastructure-now • Increased funding to support construction and expansion of community health programs-now

19. The Affordable Care Act:Impact to the Physicians • Incentives for physicians to form Accountable Care Organizations (ACO) • Large organizations of physicians and administrators who assume risk in efforts to improve outcomes and decrease costs • Various models, no consensus on specifics yet • Hospital value-based purchasing program • Reimbursement linked to hospital performance • Publicly reported outcomes

20. The Affordable Care Act:Impact to the Physicians • Bundling of payments • Combined “flat rate” reimbursement for a “whole package” of services (ie. radiology, lab, physician, hospital and other provider service fees) • Increased reimbursement to rural health providers • Meant to attract and retain providers to these areas

21. The Affordable Care Act:Impact to the Physicians • Increased Medicaid payment • Equal to Medicare in 2013 and 2014 • Fully federally funded • Increased payment to physicians by 2015 based on quality of care and not volume

22. The Affordable Care Act • Estimated deficit reduction • > $100 Billion over 10 years • > $1 Trillion over 20 years • More information • HealthCareAndYou.org

23. The Affordable Care Act • Barriers to implementation • Constitutionality lawsuits • House of Representatives efforts • Votes to repeal • Denial of funding • Senate efforts • ICD-10 code modification/derailment

24. Physician Payment Rule 2011 • Waves Medicare part B deductible and the 20% coinsurance for preventive services • Increased payment levels for E&M codes • 99213 Payment 56% higher than 2006 level • 99214 Payment 48% higher than 2006 level • 10% Medicare primary care bonus • Estimated 80% of FPs will qualify

25. Physician Payment Rule 2011 • Sustainable Growth Rate (SGR) not repealed but extension passed for 2011, delaying 23% Medicare payment reduction • 29.5% Medicare payment reduction in 2012 if SGR not repealed or delayed again • Decreased payment to some specialties (ie. Cardiology and nuclear medicine) based on practice expense revisions • Continued elimination of consultation codes

26. Physician Payment Rule 2011 • Continue to support e-prescribing and Physician Reporting Quality initiative (PQRI) • Less incentive payment than 2010 • Phasing out with payment reduction afterwards • PQRI changing name to Physician Quality Reporting System (PQRS) • Can’t receive both EHR and e-prescribing incentives

27. Physician Payment Rule 2011 • Improved payment for intranasal and oral immunizations • Improved payment for vaccine counseling/administration • Support/payment of provisions as provided for in the Affordable Care Act • Annual Medicare well visit • Removal of barriers to preventive screening • etc

28. HITECH Act • Health Information Technology for Economic and Clinical Health (HITECH) Act • Goal • To improve American health care delivery patient care through an unprecedented investment in health information technology (HIT) • Achieved through support, coordination, connectivity and promotion of the meaningful use of EHR

29. HITECH Act • Health information technology research centers (HITRC) • To research and gather measures with proven efficacy of achieving goals • Regional extension centers (REC) • Disseminate useful information, support and assist with implementation of measures

30. HITECH Act • Goals of HITRC/REC • Provide outreach within the next 2 years to at lease 100,000 patient centered medical systems • Support health information exchanges • Support Strategic Health Information Technology Advanced Research Projects (SHARP) program • Measures to expand the HIT support workforce • Non-degree curriculum development and training support through grants and competency programs

31. HITECH Act • EHR Meaningful use incentives • Medicare – up to $44,000 per provider over 5 years • Reimbursement reduction if non-compliance by 2015 • Medicaid – up to $63,750 per provider over 6 years • No Reimbursement reduction if non-compliant • Providers may only participate with one incentive • Hospitals may participate in both incentives

32. AAFP Efforts • The definition of meaningful use in the EHR incentive program • Advising CMS on graduate medical education (GME) outpatient payment system • Advising appropriate government agents as to the AAFP principles of ACO • Provided feedback on the Department of Health and Human Services (HHS) National Healthcare Quality Strategy and Plan

33. AAFP Efforts • Cautioned CMS to not solely base their reimbursement rates on the recommendations of the AMA’s Relative Value Scale Update Committee (RUC) • Successfully advocated for exceptions to the Medicare PCP bonus eligibility criteria for rural physicians • Continuously nominating family physicians to serve on federal councils which are and will be affecting the future of medicine

34. Sources • www.aafp.org • www.healthcareandyou.org • www.ama-assn.org • www.healthcare.gov • www.cms.gov • www.avalerehealth.net • www.healthit.hhs.gov

35. Definitely NOT the end! • Questions?